Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Monday, October 31, 2005

There was an anti-war demonstration in Boston on Saturday, attended by more than 2,000 people. There were also six (6) -- as in 10 - 4 or 2 x 3 -- counterdemonstrators. The story appeared inside the Boston Globe, in the metro section, on Sunday. But guess what was on the front page? A photograph of one of the counterdemonstrators, waving her "Support our Troops" sign.

Meanwhile, what are our troops up to? According to ABC News, which is nothing but a front for the communistic, terrorist-supporting, America hating Disney Corporation:

Before dawn Monday, Marines backed by jets attacked insurgent positions near the Syrian border, destroying two safe houses believed use by al-Qaida figures, a U.S. statement said. The statement made no mention of casualties, but Associated Press Television News video from the scene showed residents wailing over the bodies of about six people, including at least three children.

At the local hospital, Dr. Ahmed al-Ani claimed 40 Iraqis, including 12 children, were killed in the attack. But the claim could not be independently verified.

APTN footage from the scene showed Iraqi men digging through the rubble of several destroyed concrete buildings with a pitchfork or their hands. In the building of a nearby home, women cried over the bodies of about half a dozen blanket-covered bodies lined up on a floor. Some of the blankets were opened for the camera showing a man and three children.

"At least 20 innocent people were killed by the U.S. warplanes. Why are the Americans killing families? Where are the insurgents?" one middle-aged man told APTN. "We don't see democracy. We just see destruction." He didn't give his name.

Rosa was frightened. Her little boy Diego was sick again. Diego had asthma, he’d had a positive TB test, he had recurrent ear infections and had been operated on twice to have tubes placed to drain his ears. Two months ago a doctor told her Diego had salmonella, and the clinic had mailed her a letter about it, but she couldn’t read it because it was in English. Now Diego had been up all night with a fever and vomiting, and his ear hurt again. When they came to the clinic, there was no-one to interpret, so Diego’s twelve year old sister Juanita had to do it.

Juanita did her best, but when she tried to translate her mother’s questions, the doctor just ignored her, or wouldn’t even let her speak. Juanita tried to tell the doctor that Rosa was worried about a lump on the baby’s lip, that she wanted to know what the letter said about the salmonella, that Diego had had diarrhea and fever. But the doctor just said the letter was too old to worry about. Then the doctor asked Rosa what Diego took for his asthma, but Juanita didn’t translate the question correctly. The doctor asked how long ago Diego had his last asthma attack but Rosa thought she had asked how often he took medicine for his asthma, and the doctor’s question was never answered. Rosa tried to ask what was wrong with Diego’s ears, and what she should do if he kept vomiting, but her questions were never translated. Then the doctor said to give him Tylenol or Advil, but Juanita told her mother to give him both.

When my colleague Irma Rodriguez interviewed Rosa after the visit, she asked if the family had been back to Puerto Rico to visit. No, said Rosa, nor can we. Why not? “Because the father of the children is hunting us to kill us.” Rosa said she was going to keep on living and fighting for her children, but now they were staying in a homeless shelter. Juanita had seen her father repeatedly beating her mother, and was in psychiatric treatment for post-traumatic stress. But the doctor never learned any of this.

Communication is the most fundamental requirement of medical practice. Taking care of people is not just about biomedical science, although technically precise communication is essential. It depends on mutual trust, rapport, and the exchange of experiences, beliefs and feelings. Facilitating communication across a language barrier is a demanding professional skill. An interpreter must be truly fluent in both languages, but much more than that is required. Interpreters must be conversant with medical concepts and terminology. They must possess special skills for mediating the structural differences among languages and the deeply embedded differences in world view. Interpreters must also have skills to mediate culturally determined expectations about interactions, the physician and patient role, and theories of physiology and disease. Interpreters must meet high ethical standards. They must scrupulously respect confidentiality and avoid injecting their own judgments into an interaction that properly belongs to physician and patient.

Obviously, children can never meet these requirements. Furthermore, having children interpret places demands on them that may be overwhelming and frightening, and may expose them to inappropriate or upsetting information. A 15 year old girl told us that she was serving as interpreter for her mother, when she found she didn’t understand what the doctor was saying, so they called for a Spanish-speaking secretary to help. “Don’t you understand what they’re telling you?” the secretary asked her. The girl went on, “’No, I said.’ She tells me, ‘They’re telling you’re your mother has,’ some sort of thing, cancer, I don’t know, I was like, ‘No, I don’t understand what you’re saying’ . .. and the lady was just so rude.” Doctors in England have told of a child from India who was traumatized by having to interpret for her family during her brother’s fatal illness.

Sunday, October 30, 2005

The cnidarians (formerly called the coelenterates) are a successful animal phylum. They are almost exclusively marine, except for some aquatic representatives of the sub-pylum hydrozoa (hydras). Beachgoers are very familiar with the jellyfish. Corals and sea anenomes are also cnidarians, as are some less familiar creatures.

The cnidarians possess a nerve network, but no brain -- no central processing unit. Unlike the chordates, to which we belong, and the many animal phyla more closely related to us, they have only two embryonic tissue layers, as opposed to our three. They have an important asset belonging to no other phylum, called the nematocyst -- a mechanism in specialized cells that shoots out a stiff thread. In most cases, this thread is a poisonous dart. Nematocysts are typically found in the tentacles which surround cnidarians' mouths, and are used to kill prey which the tentacles then transport to the mouth. But nematocysts also function for adhesion, locomotion, and other purposes.

While we may pity the cnidarians for their lack of a brain, they are at an even greater disadvantage from lack of an anus. We three-layered creatures have a tube running the length of our body cavities. Food enters at one end, is systematically disassembled, and its useful contents assimilated. The dreck eventually exits at the other end. Cnidarians have a much less efficient system. They have only one opening to the digestive cavity. In order to ingest a meal, they must open the door, so that whatever contents are already present may escape, whether or not they are fully digested. When cnidarians swim, the cavity is inevitably distorted and its contents may be expelled. Even less happily, from our idiosyncratic point of view, cnidarian gametes -- sperm and ovae, essentially -- are discharged into the same cavity. To be exchanged with the opposite sex -- or a fellow hermaphrodite -- the gametes must be expelled into the oceanic environment along with lunch.

It's sad that we have so little appreciation for one of our most important assets. It seems an undeserved honor to label Pat Robertson, Jerry Falwell, James Dobson, and their friend in the White House by a name for this essential body part.

Commenter Tyler writes, in response to my previous post mentioning Rep. John Boehner, "If you knew anything about the man, you'd know he's fought against Democrat attempts to cut child nutrition programs in his own committee (Education & Workforce). The ignorance of the left never ceases."

Now, I certainly welcome criticism and debate, although I don't welcome gratuitous insults -- I am definitely not ignorant. So I hope Tyler will continue to visit and engage us in discussion here, in a civil and respectful manner.

As for the facts of this matter, the Democrats obviously support spending for child nutrition progams at a higher level than do the Republicans. In fact, Mr. Bush has proposed (again) cutting these programs in the new budget, and the Democrats on Rep. Boehner's committee oppose these reductions. (Subsidized school lunches, the WIC supplemental nutrition program, and some other programs to feed needy kids in homeless shelters, summer camps, etc. are normally wrapped up in a single piece of legislation.) The issue in question was not that Democrats wanted to "cut" these programs. Rather, it had to do with nutritional quality of school lunches. As James Weill, Director of the Food Research and Action Center, testified before the corresponding Senate Committee:

We have to improve the nutrition environment in which children consume the meals and snacks offered in the child nutrition programs. The Secretary of Agriculture should have the authority to control the sale of competitive foods throughout the school from the time school opens in the morning until the end of the last lunch period, in order to ensure as much as reasonably possible the healthfulness of foods offered to children. Other steps to improve health and reduce obesity should be part of this process.

Boehnert opposed giving the Secretary this authority. In the new legislation, local schools are required to develop their own "wellness" programs, but there will be no federal standards for the content or quality of these programs, or the quality of school meals. It is likely, obviously, that local school districts will often be ineffective at getting junk food out of their schools. To portray this dispute as an effort by Democrats to "cut" child nutrition programs seems fundamentally, ahh, disingenuous, shall we say?

It's no surprise that Boehnert would take this position. While he receives the largest share of campaign funding from the financial industry, he is a significant beneficiary of campaign funding from the Food and Beverage Industry ($8,375 in 2005-6); Food Production and Sales ($11,520); Retail Sales (including convenience stores -- $8,500); and, interestingly though perhaps off topic, Alcoholic Beverages ($17,000). More important than his personal campaign fundraising, no doubt, is Boehnert's role as a major fundraiser for Republican causes in general -- he has his own PAC -- and as a K Street power broker. According to Jonathan Kaplan writing in The Hill:

Rep. John Boehner (R-Ohio), a likely candidate for a position in the House Republican leadership if former Majority Leader Tom DeLay (R-Texas) does not return, has assembled a loyal and effective network of lobbyists.Boehner formed his alliances on K Street when he served as chairman of the GOP conference from 1995 to 1998, when his portfolio included working with lobbyists on K Street.

“He was a policy traffic cop for the business community,” one of Boehner’s allies said. “When [former Rep. J.C.] Watts [Okla.] won [the election for conference chairman], DeLay, in the whip position, vacuumed in the policy and business outreach. He added staff and translated business outreach into votes, which is something [Missouri Rep.] Roy [Blunt] is doing now.”

Many GOP sources say Boehner would receive strong support from his so-called K Street Cabinet if he decides to run for another leadership post. He is considered a strong contender to become majority leader or speaker if DeLay, who is under indictment on charges of conspiracy and money laundering in Texas, does not return to his post or if Speaker Dennis Hastert (R-Ill.) retires in 2008.

The sources add that Boehner would likely be able to count on strong support in either case from these lobbyists:

• Dirk Van Dongen of the National Association of Wholesaler Distributors.

“It’s a pretty broad-based orbit and relationships of people who saw him as a rising star when he was just a junior member,” said a senior GOP lobbyist close to Boehner.

Gates and Gandy hosted the first of the now-famous warehouse parties that have become regular features of Republican national conventions and are referred to as “the Boehner parties.” The first was in 1996 in San Diego.

While many lawmakers use Washington’s button-down restaurants to host fundraisers, Boehner and his allies prefer the more relaxing Cantina Marina, a bar and restaurant noted for its Gulf Coast and Cajun fare, located on the Potomac waterfront in Georgetown, several of the lobbyists said.

Each August, Boehner diligently raises money for members of his Education and the Workforce Committee, GOP challengers and vulnerable incumbents; this summer the beneficiary was Rep. Cathy McMorris (R-Wash.).

And, as for my other characterizations, Boehner is a vocal backer of the Iraq war and of increased military spending; of Social Security privatization (and simultaneously, and opponent of protections for small investors); and of yet more tax cuts for the wealthy.

It is, unfortunately, a common practice of the political right to fundamentally misrepresent the policy positions and actions of their opponents. For example, Max Cleland and other Democratic Senators were attacked for opposing the president's efforts to "protect the homeland" because they advocated for employees of the new Department of Homeland Security to be covered by civil service protections.

Tyler, there may well be arguments on both sides of the dispute over school lunches, but you fundamentally mischaracterized it. And you cannot deny that Boehnert, in his role on the Agriculture Committee, is trying to cut funding for food stamps, even as more and more Americans are going hungry, which is what I posted about in the first place. Do you care to defend that? I'll be happy to discuss it.

Saturday, October 29, 2005

What with all the excitement lately, you have to turn a few pages to find out about unimportant stuff like the federal budget, but just so you know, the House Agriculture Committee yesterday voted to take food stamps away from 300,000 people, which would also have the effect of taking subsidized school lunches away from 40,000 kids.

As Rep. John Boehner (R. Ohio) put it: "The fact is, our country is going broke. We're spending money we don't have and passing it onto our kids, and at some point, somebody's going to have to say, 'Enough's enough."

Right Mr. Congressman, we're passing that debt on to our kids -- at least the ones who live long enough and are productive enough to have to pay it, because we didn't starve them when they were five years old. (The government also reported yesterday that the number of people who can't afford to buy a sufficient diet rose last year to 38.2 million, that's 12 percent of Americans. Thanks to Libby Quaid of the AP for putting this particular two and two together.)

So I'm gonna say it. Enough's enough. Let's stop spending $5 billion a week to defend the Shiite side in the Iraqi civil war that we started. Let's stop getting our young men and women killed and maimed in the process. Let's stop spending money on useless and dangerous projects like ballistic missile defense and biological weapons research. Let's stop building bridges to nowhere, and endlessly cutting taxes on the wealthiest Americans. And let's throw these greedy, lying, war mongering hypocrites like John Boehner out of office. Enough's enough.

Friday, October 28, 2005

Then there's the small matter of mass murder. That would be 2009 dead American soldiers and marines (as of this minute), 97 dead from the UK, 102 soldiers from various countries in the Coalition of the Billing, 60 journalists (that we know of), 276 "contractors" (that we know of -- mostly mercenaries).

And oh yeah, something between 40,000 and 120,000 dead Iraqis, depending on who you ask, but hey, who's counting? And we definitely aren't counting the starving children. Anyway, death is a small price to pay for being liberated.

Thursday, October 27, 2005

I wrote a couple of months back about European studies that called into question whether routine screening mammography really reduces the breast cancer death rate, at least for women not at high risk. A new analysis commissioned by the National Cancer Institute finds that screening has contributed substantially to the decline in breast cancer deaths in the U.S. Caveats still remain: most lesions found by screening are benign, and you have to go through all the sturm und drang. Probably something like 30% of cancerous lesions wouldn't have gone on to cause clinically significant disease, but you have to go through surgery and chemo anyway because the docs can't tell the difference. But most women will probably decide it's worth it for the survival benefit. Still, talk it over, make up your own mind.

Is this really a major problem, or more "War on Drugs" hype? Some burn specialists in rural areas are saying that the number of people burned in home meth lab accidents is straining their resources and forcing them to ship innocent victims of house fires out of the county. But David Duncan, a research consultant, says "There are just not enough [meth lab explosions] to cause a national problem for burn centers. . . . And while meth lab cooks are not likely to have insurance coverage, their numbers are tiny compared ot the millions of people losing Medicaid coverage or working for companies cutting back on health coverage." Right on. (Reporting by Mike Mitka.)

Quackery: There's a mass marketing campaign -- totally illegal, as a matter of fact -- for Human Growth Hormone as an anti-aging elixir. Fuggedaboudit. Not only does it not work, and cost hundreds of dollars a month, it causes joint pain, muscle aches, edema, probably diabetes and, oh yeah, maybe breast cancer. Vile scum, that's what they are -- many of them M.D.s. (Commentary by Thomas Perls, Neal Reisman, and Jay Olshansky.) I recommend Quackwatch, even though some of my friends will think the proprietor, Stephen Barrett M.D., suffers from excessive orthodoxy. Maybe so, but you need to hear his point of view.

After my class last night I stopped off at the local watering hole for some dinner, and the World Serious was on. Poppy and Babs were at the game, and of course the Fox cameras kept caressing them lovingly.

They were having a Grand Old Time! They didn't have a care in the world, they were as happy as hogs in slop, and Babs had an extra bucket of potato peels and apple cores. At first I thought, "That's a little odd," then I realized -- they're happy to watch Junior stepping in it.

Babs was thinking, "If I had a pearl necklace for every time we've had to pull that boy's lazy, smug, dumbshit sorry ass out of the deep doo doo . . . It got so tiresome, I was growing pimples on my beautiful mind. Well he's on his own this time, we aren't loaning him five bucks for a shoeshine. We're just drinking martinis for lunch now, sitting on the front porch watching the sailboat races. His uncle Dick can't help him either, he's swimming in the doo doo himself. Which is also just fine by me. I never could stand the way that man talks with his jaw clenched, such a sourpuss.

Anyhow, maybe this will finally ram some sense and some respect through Junior's concrete cranium, but frankly, at this point, I don't give a rat's ass."

At least that's how it appeared to me, but I only saw a bit of video of people I've never met. Maybe Dr. Frist has a better diagnosis.

Wednesday, October 26, 2005

Just so y'all know I'm reality based, rather than a constitutional depressive, let us all take note that the aspiring king and his court are indeed severely weakened. They've caved on suspending the Davis-Bacon prevailing wage law in the hurricane zone, and they've caved on developing new generation nuclear weapons -- tactical so-called "bunker buster" bombs designed for first use.

Much to their credit, CBS News not only has a well written story on this, but an interactive primer on nuclear weapons and nuclear dangers in the modern world. (Click the "interactive" links in the left side bar.)

Now, do we have a chance to stop the Congress from passing yet more tax cuts for the wealthy while taking health care, housing, and fuel assistance from the poor?

This is from our friends at Community Catalyst: (They had a call in day on Oct. 18 but it's not too late, these issues are still in play.)

------------------------------------------------------------------------------------Katrina Survivors Need Medicaid Medicaid must not be cut!

The tragedy on the gulf coast has affected thousands of African American and low-income residents who depended on Medicaid and other programs, such as food stamps and subsidized housing. They will need emergency assistance to meet their immediate needs and to rebuild their lives. Emergency Medicaid is the best way to make sure that survivors have ready access to the full complement of physical, mental health and long term care supports and services they may need over the coming months, and that Medicaid can easily and efficiently provide, no matter where survivors are temporarily living.

"Ensuring that these individuals get access to health care, wherever they are, is our biggest issue," said Dr. Fred Cerise, who heads Louisiana's Department of Health and Hospitals. Tribune,September 14, 2005.

Set Congress's Priorities Straight! Call Capitol Hill and tell your Senators and Representatives not to cut life saving health care services Katrina hurricane survivors need. Let them know you oppose cutting Medicaid, Foodstamps and other vital programs to pay for for the hurricane relief. A new bipartisan proposal, supported by Senators Grassley and Baucus as well as members of Congress from the states hit by the hurricane, would immediately provide Medicaid coverage to low-income Katrina survivors. However, this proposal has been blocked by the Bush administration, and further delays immediate aid to Katrina stricken areas.

In this time of need, the Administration opposes paying 100 percent of the cost of coverage and administration, and expects each state to foot all or part of the bill. The Administration has made even more dangerous proposals:

Even more cuts! In response to the increasing cost of the Katrina damage, Congress may cut even more deeply! The House has already delayed the FY 2006 budget reconciliation and has set a higher target for cuts to programs such as Medicaid, Food stamps and other vital services. States are on their own! Refusing to financially support states for Katrina relief leaves states vulnerable and may lead to further state cuts in Medicaid, denying benefits and coverage to those who rely on the program. The poor are punished and the wealthy are rewarded! Federal tax breaks for the "well-off and well connected" are hurting middle and low income people. But plans to pass more breaks for the wealthy are proposed in the budget. This will result in more cuts of vital services that we all need, especially those who are vulnerable. Stopping the tax cuts for just one year would be more than enough to pay for the entire costs of Katrina/Rita recovery.

What we can do:

Call your Senators and Representatives and tell them that these cuts are devastating and unacceptable! Instead of cutting much needed life saving programs, Congress should:

Call on Majority Leader Frist to bring Grassley- Baucus up for a vote now: Each day that passes, more lives are put at risk. This legislation should be enacted on an emergency basis as soon as possible. People from the disaster areas have been forced to wait for help for too long. Not make cuts in the FY2006 Budget to life saving programs such as Medicaid. Cost-savings in Medicaid that do not hurt beneficiaries are possible through prescription drug pricing reform. However, this should be done separately from the budget proposal to make sure savings help stabilize Medicaid. Not increase tax breaks for the wealthy while middle and low income people are struggling to make ends meet.

The corporate media and the "opposition" party have long had definitive, fully public evidence of a horrific crime. A small group of top administration officials -- the president, vice-president, secretary of defense, and some of their confidants -- decided to make war on Iraq, probably even before the Bush administration took office. Acting in secret, they set out to manufacture a casus belli, conspiring with a convicted embezzler who they intended to install as president of "liberated" Iraq, and, among other "journalists," a New York Times reporter. Oh yeah, British Prime Minster Tony Blair and some of his cabinet ministers were in on the conspiracy. Meanwhile, they allowed the foreign policy apparatus to go through the motions of normal functioning, as a distraction to the press and public, although the conclusion was fixed long ago. They even chose to ignore the extensive planning done by the state department for the contingency of a post-war Iraq, simply because it wasn't a part of their conspiracy.

As for the devastating consequences of this crime -- the cost to Iraq, to the United States, to the world -- I won't belabor the obvious. How very disturbing it is that there was no prospect of bringing any of the conspirators to account until a prosecutor was appointed to investigate a relatively minor, certainly peripheral action in furtherance of the conspiracy. The Democratic Party has largely supported the conspiracy, including its most prominent prospective presidential candidates; the corporate media have criticized it mildly but have certainly not chosen to regard it as a crime of any sort, let alone treason and mass murder. The majority of commentators given access to the mass media regard the specific crime under official investigation as a trivial technicality, and disparage the prosecutor as overzealous.

Fortunately, a good portion of the citizenry feels otherwise. We have been betrayed by our leaders. Perhaps they will finally feel our anger.

Tuesday, October 25, 2005

With all the bureaucratic reorganizing, redirection of public health funding, and presidential and vice presidential squealing and yapping about bioterrorism, you probably figure we've made major progress in preparing for possible epidemics. Yeah yeah, it probably won't be "bioterrorism," but just a natural event such as pandemic flu or a more novel infection, but the necessary infrastructure and plans are about the same, right?

Maybe, I dunno. But just as a reality check, this is what the national bioterrorism (and/or infectious disease emergency) plan consists of: templates and checklists, that state health departments post on their web sites, for cities and towns to follow. It all falls on your local Board of Selectment and Commissioner of Health -- the guy who inspects the hamburger stands to make sure the screen doors are intact.

These researchers pretended to be nurses or citizens, and they called the hotline number of various local public health agencies, reporting what appeared to be cases of bubonic plague, anthrax, smallpox, etc. Fewer than half of the agencies met the federal guideline of responding within thirty minutes. Some of them didn't get back to the caller for more than an hour and four did not return calls at all. Three of them didn't call back after being called five times.

Once they did manage to reach a responsible party, responses varied:

Respondents varied widely in their handling of simulated cases. Several action officers asked relevant questions about the location of the patient and about clinical details, but in several cases the responses were troubling. For example, among respondents presented with a case report from an emergency department physician of a patient presenting with “pustules on the face, arms, and legs with lesions in the same stage of development,” none suggested isolation of the patient or advised the caller to use personal protective equipment. Similarly, when presented with a case consistent with botulism, one action officer responded, “You’re right, it does sound like botulism. I wouldn’t worry too much if I were you.” In response to classic symptoms of bubonic plague, the action officer told the caller not to worry and to “go back to bed” because no similar cases had been reported that day.

I'm going to write quite a bit more about this general subject in coming days (and check out Effect Measure as well on this), but this will get us started. We need to be engaged with our local governments, big city or small town, if we want to make sure we're ready. The top down approach is not working.

Monday, October 24, 2005

Since Haloscan seems to be down for a while, this is probably a good time for me to talk a bit about my actual research. For whatever reason -- I need a vacation? I'm just too modest? -- I haven't talked about it a lot here, but I study physician-patient relationships and communication. I used to say that I focus on language and culture as factors in the above, but now I've decided that's like saying I focus on building techniques as a factor in construction methods. All doctor-patient communication is cross-cultural and bilingual.

It might be said that communication is the most important clinical skill. Certainly it is the skill that is used the most. A typical physician visit - or medical encounter, as some would have it - is occupied with almost continuous speech, mostly in the form of what we call a conversation -- a back and forth exchange of utterances between two people. This is not very much like the conversations we have with our friends, family members, co-workers, lovers, or anybody else, for that matter. These are highly ritualized, asymmetrical encounters that are powerfully shaped by cultural tradition, the way in which physicians are socialized and trained, our previous socialization and experience of medical encounters, the instrumental goals of the visit, time constraints, legal requirements, inequality in possession of information and social status, and other factors. As complex as they are to describe and understand, they are often as critically important. Their success or failure can mean health or illness, life or death, and even if nothing that dramatic is at stake in a particular instance, they can greatly affect how we feel -- whether we are reassured, anxious or even terrified, satisfied, frustrated, guilty, proud . . .

There is an immense literature on this subject. There are many instrumental purposes for MD/PT communication, obviously -- diagnosis, treatment decision making, emotional support, personal relationship building. The funding I have right now happens to concern the objective of motivating behavioral change, and more specifically achieving better adherence by patients to prescribed medication regimens, but the work I'm doing is much more broadly applicable. Here is a link to a review just this week of how people think about this issue, which includes some concepts similar to ones I am working with.

What I am trying to bring to the party is a new way of characterizing and analyzing conversation based on an idea in sociolinguistics called Speech Act Theory. You'll notice in the BMJ article concepts such as informing, open questioning, directing, etc. These are rudimentary representations of Speech Acts -- specific kinds of social resources that are exchanged in conversation. Representatives (statements of fact about the world), Expressives (assertions about one's inner reality), Questions of various kinds (which place a social obligation on the interlocutor to respond), Directives (intended to influence the interlocutor's behavior, whether in the form of mandates or suggestions), Commissives (promises and official acts affecting one's status), Praise and Insults, Affective exchanges, Social Ritual, Conversation Management, and others. These are properties of speech in all languages, and they are only loosely and inconsistently related to grammar and syntax.

One can define a completed speech act as a unit, called an utterance, classify it as a speech act, and then classify it according to topic -- what is being discussed. In this way, we develop a rich and revealing quantitative description of an interaction. We are developing computer software to facilitate the coding process.

Where this all leads, I hope, is to a convincing way of consistently characterizing and understanding interaction processes, and the amount and quality of information and other social resources that passes between physicians and patients. We can relate this to outcomes -- such as better medication adherence, patient satisfaction, informed decision making, etc. -- and to inputs such as physician training and other interventions.

It probably sounds rather arcane and boring. One of the great difficulties in social science is in linking levels of analysis. Critical discussion of systems such as the medical institution and public health infrastructure, policy analysis -- these macrosociological fields are usually more exciting than the minutiae of individual encounters. But they are connected. Medicine is hierarchical, unequal, embedded in the our unequal society and shaped, in the U.S., by our powerfully individualistic cultural norms. All of this manifests in the particular.

Sunday, October 23, 2005

This is unbe-fucking-lievable. Former Florida Senator Connie Mack, Chairman of the tax "reform" panel, is interviewed by the New York Times Magazine. He's wants to eliminate the estate tax -- it's so unfair -- and he says there's no way there's going to be any tax increase. The following ensues:

Q. Well, the U.S. government has to get money from somewhere. As a two-term former Republican senator from Florida, where do you suggest we get money from?

A. What money?

Q. The money to run this country.

A. We'll borrow it.

Q. I never understand where all this money comes from. When the president says we need another $200 billion for Katrina repairs, does he just go and borrow it from the Saudis?

A. In a sense, we do. Maybe the Chinese.

Q. Is that fair to our children? If we keep borrowing at this level, won't the Arabs or the Chinese eventually own this country?

A. I am not worried about that. We are a huge country producing enormous assets day in and day out. We have great strength, and we have always adjusted to difficulties that faced us, and we will continue to do so.

Anyone who teaches in higher education occasionally encounters students who have found the single key that unlocks every puzzle of politics and policy. The highest principle is human liberty, the essence of liberty is control over one's own property, and the greatest threat to that liberty is government. While one might be concerned about problems of justice or social welfare in the absence of government, those concerns are illusory. The Free Market, operating without government intervention, maximizes social welfare and produces justice by rewarding the talented and enterprising. Taxation is by definition immoral, because it deprives people of their property. Regulation is immoral because it restricts people's liberty to do what they wish with their property, and it is harmful to the general welfare because it deprives us of benefits the Free Market would bestow upon all.

It is trivially easy to debunk these arguments. Obviously, it is not only government that can deprive us of our liberty, but also individuals and private interests. At the most basic level, we have police and criminal laws -- government agencies -- to discourage people from robbing us, raping us, kidnapping us, killing us, and taking other actions which might deprive us of our liberties. Libertarians generally concede this, but they somehow can't see the generalizability of the principle, for example to regulation of business enterprises that might deprive us of liberty and property in innumerable ways. Perhaps more centrally, property does not exist by nature, it is bestowed by law and regulation. People gain and lose it not only by talent and enterprise or the lack thereof, but by fortune of birth and timing, ruthlessness and dishonesty or charity and altruism, generosity of others or victimization, and so on. Finally, and most fatally, there is no such thing as a "Free Market." Markets, in complex societies, are creations of government, and can only exist with the benefit of contract law and enforcement, government regulation of the money supply, banking and exchange regulations, and so on. The arguments that markets can maximize allocative efficiency depend on numerous assumptions that can only be made to approximate the truth by extensive government intervention, such as no monopoly power, perfect information, no externalities, and several others. Furthermore these arguments ignore the existence of a public domain. And the truth is that even the most conservative and market fundamentalist economists have no argument that shows that markets produce anything that resembles justice.

So why is this patently absurd and counterfactual philosophy so appealing, and why does it retain a place in the public discourse? It constitutes a defense of privilege, and it is a friend and comfort to the powerful. That is why economics departments and business schools, which are largely endowed by wealthy people and corporations, indoctrinate students with ideas that can be knitted into this cloth. It is useful in politics for the same reason, although corporate interests and wealthy individuals are quite happy to temporarily forget about it whenever they want government to do something for them.

All that is understandable. What I have difficulty understanding is how this supremely amoral philosophy, this apologetic for ruthlessness, greed, and injustice, is now championed by the most vocal and influential politically active Christians in the United States. I received an e-mail from a reader who informed me that Jesus was the first libertarian, and that Christian libertarianism will triumph. Of course these same Christian libertarians, when it comes to examples of your property such as your genitals and your womb, don't agree that you should be free to do with them as you please. Very puzzling indeed.

Saturday, October 22, 2005

Cervantes is off in the woods building a cabin or something, so I'm keeping the blog warm. Another Hurricane bearing down on the south, but the effects of two hurricanes ago are not close to worn off. Consider this.

Just before Katrina hit the fucked up state of Louisiana, the police there were doing what they do best, protecting everyone by arresting poor folks for minor offenses, like sleeping in public, begging, dealing Tarot cards and being drunk where others can see them. Thousands were in the slammer awaiting initial hearings before local judges when Katrina hit.

Six weeks later. Hundreds are still there, yet to come before a judge. Most should have been free long ago after their 10 day sentences, even if found guilty. Instead they're still locked up.

Local parish prisons—the equivalent of a county jail—in six Louisiana parishes hit hardest by the hurricane held more than 8,500 people when the storm hit. These detainees were evacuated to 43 state and local facilities across the state. Several hundred were sent to Florida as well.

[snip]

Local courts that have the authority to release the detainees remain closed. Although criminal defense attorneys, on October 6, asked the Louisiana State Supreme Court to grant jurisdiction to a single judge to hear all cases originating from the six affected parishes, the court has not yet ruled on the request. If denied, lawyers will be forced to file separate actions in the 26 separate judicial districts where the arrestees are now being kept, a monumental task for the lawyers who are working as volunteers—many of whom are New Orleans evacuees themselves. (Human Rights Watch)

It turns out this isn't just the usual Louisiana dysfunction, either. It's deliberate.

Prosecutors and department of corrections officials have not simply dragged their feet, however. They have also actively sought to impede the release of those who should be free. In habeas and civil rights proceedings brought on behalf of some 200 prisoners, the state’s attorney general, the district attorney, and the department of corrections all argued that the court should delay releasing those who served their time until they could demonstrate that they had somewhere to go when they were released. There is no requirement under Louisiana law, however, that those released after serving their sentence inform authorities of where they intend to go.

A spokeswoman for the department of corrections told the Times-Picayune last week that the department was concerned about the “wave” of prisoners being released into communities throughout Louisiana with “no place to go.” In habeas proceedings in one municipal court, the corrections department has said it would release people in alphabetical order, 35 or so a day, excluding weekends.

Friday, October 21, 2005

As I have noted before, the place to find the health care policy news is in the business section -- not that there's anything wrong with that. For example, today the Boston Globe has four stories on the front page of its business section, three of which are about health care, plus teases to two more health care stories inside. So now we know what constitutes the largest industry in the United States, and what really drives our economy.

The stories are about blood clotting associated with coronary artery stents; a Massachusetts Medicaid HMO that is adding dental coverage for its members (Hooray! Worth a story when I get back from the boondocks this weekend); the Cleveland Clinic Foundation stepping up to try to kill what otherwise appeared to be imminent FDA approval of a new drug for Type II diabetes, called Pargluva, which its sponsors Bristol-Myers-Squibb and Merck apparently didn't bother to point out doubles the risk of heart attacks and strokes (Some people are just so hypercritical, aren't they?); Pfizer's earnings get whacked on the Celebrex and Neurontin debacles (which, by the way, is not the fault of the stockholders but they're the ones who pay, not the executives who were responsible. Just sayin'); and finally, the one I'm going to say something about here, which is that community hospitals in Massachusetts are hurting big time.

The reason? Almost half the patients in the state are going to the big name, famous teaching hospitals. The community hospitals aren't filling their beds, are losing money, and are having trouble finding capital to modernize and keep up their capacity. Of course, the teaching hospitals are much higher cost providers, which hurts payers and ultimately, consumers and taxpayers as well.

Okay, you are probably saying, but it's only natural that the people want the best for themselves and their families, and of course they go to the academic medical centers where all the Top Docs (as the tabloids will have it) are to be found. Well I've got news for you -- unless you're going for the latest experimental procedure, such as a face transplant, or high risk surgery where your local hospital is not a high volume provider (surgical teams get better with practice), you're much better off going to your friendly, neighborhood community hospital.

If you go to A Major Teaching Hospital of The World's Greatest University, the Top Docs will be around someplace in the building, but the doctors who actually do things to you will be inexperienced residents who haven't slept for 36 hours. Half the people who draw your blood and set your IVs will be doing it for the first time, and you're likely to end up with an arm like a 12 bag a day junky. Not only will the sleepless resident want to stick his finger up your ass, but so will 12 medical students. Every morning, a gang of 8 people will come in at 6:00 am, wake you up, and stand at the foot of your bed discussing you as if you are some non-sentient entity in another state.

Surveys consistently show that patients are much more satisfied with their experience at community hospitals than at teaching hospitals. And for most of the reasons why people go to the hospital, they get equally good or better care. Plus it's a lot easier to park. So take my advice on this one.

Thursday, October 20, 2005

The UN says the shortfall in aid for victims of the South Asian quake has made the relief situation worse than after last December's tsunami.

UN emergency relief chief, Jan Egeland, said the organisation had never seen such a "logistical nightmare".

Mr Egeland said an airlift was needed of the proportions of the Berlin blockade of the 1940s, when Allies flew in supplies to the divided city in communist eastern Europe.

He said aid had to be sent in, and tens of thousands of homeless and injured people flown out, of remote regions before winter set in.

Mr Egeland said of the aid sent so far: "This is not enough. We have never had this kind of logistical nightmare ever. We thought the tsunami was the worst we could get. This is worse."

Mr Egeland said only $86m had been pledged of the £312m the UN had asked for to fund the relief operation - and far less actually received in hard cash.

Earlier, UN Secretary General Kofi Annan called for the global relief effort to be increased to help three million people made homeless by the 8 October quake and facing the fierce Himalayan winter without shelter.

"That means a second, massive wave of death will happen if we do not step up our efforts now," he said.

Mr Annan said that in the most affected areas hospitals, schools, water systems and roads had all been destroyed.

He called upon top international representatives to attend a UN-sponsored donors conference in Geneva, Switzerland, next week.

Mr Annan's chief aid co-ordinator in Islamabad, Andrew McLeod, told the BBC: "If the second wave of deaths hit, it's the major donors that are going to have to look at themselves in the mirror and ask why."

Now, I know the U.S. can't possibly afford to give more because we have more essential priorities such as abolishing the death tax and bringing the light of freedom and democracy to the Greater Middle East by means of expensive 500 pound bombs. But I hope that those who can afford to give will do so.

Wednesday, October 19, 2005

This is a complicated story, which is difficult to summarize, especially for those who aren't already pharmaceutical policy wonks, but I'll do my best. Pamela Sankar and Jonathan Kahn at Health Affairs tell it in all its horrifying glory.

As readers know, I am very concerned about health disparities, and I believe that health equity is a positive message that progressive activists and political candidates can get behind successfully. But it is the opposite of progress for people to start to claim that disparities are based on biological differences among the "races." Unfortunately, there is a vested interest in the race concept, and it's not just among white supremacists -- it's among people who use race (rather than ethnicity, discrimination, labeling, culture, poverty, and most to the point, racism)as their personal meal ticket. And you know who you are.

Okay. In June the FDA granted approval to a formulation called BiDil, specifically as a treatment for heart failure in African Americans. Note that African Americans are people who belong to an ethnic group -- they are not a "race." Some African Americans have more European than African ancestry. Some people in the U.S. who have predominantly African ancestry are not African American. How could this happen?

It turns out that many years ago, two generic drugs called hydralazine and isosorbide dinitrate, hereafter H/I, when used in combination, were found to be very beneficial to patients with heart failure. So they were combined into a single pill called BiDil. Then, drugs called ACE inhibitors turned out to be even more effective. BiDil is still patented, but the patent runs out in 2007. Meanwhile, there's nothing to stop generic manufacturers from marketing the two components separately. Also, the FDA had not approved BiDil (a separate step from a patent), so the patent wasn't worth anything. That's basically because the original trials weren't intended to win new drug approval, and didn't have good enough design for that purpose. (The generics didn't need approval, and there was no sense getting approval for the combined pill.)

Then, the original developer analyzed the old data by race and noticed that the 49 Black subjects on H/I seemed to do better than white subjects. Given such a small number, this could easily have been a coincidence, but it gave the developer an opening to get a new patent to use H/I specifically to treat heart failure in African American patients, and then get funding for a clinical trial for BiDil (the two drugs in a single pill), as an adjunct to the standard ACE inhibitor therapy in African American patients. Mirabile dictu, it worked. The combination of BiDil and ACE inhibitors was better than ACE inhibitors alone. So now the company, NitroMed, has applied for new drug approval, which will be good till 2020, to market BiDil specifically for African American patients.

Got all that? Sorry, go back and read it again if you have to. The point is, it probably works just as well for everybody. There is absolutely no reason to believe that it is especially efficacious for black patients, or that it won't work just fine for everybody else. But the manufacturers couldn't have gotten a monopoly on that basis. And it will cost almost $11/day, compared with a little over a buck for the two generics. Since doctors know that it really works for everybody, NitroMed hopes they'll prescribe it off label for non-Black patients (wink wink), and they'll make a fortune, but they can only market it to Black people.

As your mind boggles, consider this:

The financial incentives for drug research and development are completely dysfunctional. What companies are compelled to do to make money has little to do with rational inquiry that will benefit our health.

This sordid story means that the bogus, pseudo-scientific concept of "race" will be reified, not only in FDA policy, in a mass marketing campaign to sell pills.

Meanwhile, the research to prove that H/I is beneficial to everyone, when added to ACE inhibitors, could have been done -- but it wasn't because nobody would make a fortune off of that information. All it would have done is save lives.

From AP just now: A U.S. Air Force reconnaissance plane measured maximum sustained winds of 175 mph, with higher gusts, the U.S. National Hurricane Center said.

The plane also recorded a minimum pressure of 882 millibars, the lowest value ever observed in the Atlantic basin. That meant Wilma was stronger than any storm on record, including Katrina, which devastated New Orleans in late August, and Rita, which hit the Texas-Louisiana coast in September.

Okay then. I also read today that with the arctic sea ice disappearing, we're going to have a whole new geostrategic situation, the Panama Canal will become obsolete, and there's going to be an arctic land rush -- tough shit for the Inuit and the polar bears. The glacier on Kilimanjaro will soon be gone. You get the idea.

So, it's basically too late. We aren't going to reduce fossil fuel use any time soon, and global climate change will just accelerate anyway, no matter what. There's probably a positive feedback loop with the arctic ice cap disappearing -- the open water absorbs more sun, rather than reflecting it back like that bright white ice. The surface layer of the ocean has already warmed so it's absorbing less heat. Etc.

The time has come to figure out how we're going to live with this. The debate about Kyoto is over. We still need to accelerate conversion to renewable energy, of course, and it's got to be a political priority to undertake drastic measures to reduce exacerbation of climate change as much as we can. But we need to deal with it as a present reality, not a distant prospect.

I have some thoughts about the likely consequences and how to respond, which I will get to. Anybody else care to weigh in?

Tuesday, October 18, 2005

I imagine most of my 4 1/2 faithful readers are already up to speed on the Serostim settlement, but here's a synopsis.

The drug maker Serono developed a hormonal treatment marketed for the wasting syndrome associated with AIDS. Unfortunately, the same year they got the patent, 1996, was about when fairly effective drugs to control HIV disease came on the market, and the number of people who suffered HIV-related wasting in the rich countries, who could have afforded Serostim, plummeted.

What to do? They started pushing a test on doctors to measure patients' "body cell mass," which would conclude that some patients were "wasting" even though they did not appear to be, and so needed Serostim -- at a modest cost of 21,000 bucks. (Yup.) Now, body cell mass is a real concept (it essentially means everything that isn't fat), but this test was not approved by the FDA and there was no evidence whatsoever that these patients actually needed treatment for wasting or benefited from Serostim.

Serono also gave a free trip to Paris for doctors who prescribed Serostim. Now, that I can understand. Doctors can be criminals, just like drug company executives. But what about all those doctors who didn't get a free trip to Paris, but just took the company rep's word for it that they should use this magical device and follow its instructions to give people $21,000 worth of hormones? Do they also smoke Marlboros because it makes them manly men, and drink Dr. Pepper so they can do what they do, and drive Dodge Ram pickups so they can grab life by the horns?

Serono has admitted that "this device was not approved for the purposes of diagnosing AIDS wasting." It also admitted to the free trips to France, but the DOJ has not identified the physicians who accepted them. (Wouldn't want to embarass the good doctors, now would we? Not that their patients have any right to know that their doctors are criminals who give them useless and possibly dangerous drugs in order to win free trips.) The scheme was uncovered by whistleblowers who worked for the company. I applaud their ethical passion, but also note that they are getting $10,000,000 each in bounty money -- which can motivate a lot of virtue. However, thousands of people were prescribed Serostim, which means we are probably talking about hundreds of doctors.

Next time you visit your doctor, you might want to check for dementia.

With soon-to-be hurricane Wilma apparently heading toward south Florida and several presidential photo-ops, this seems as good a time as any to reflect on the recent spate of natural disasters.

Yup, it's real. There have been more than the usual number of major catastrophes lately and it's getting to the point where the relief agencies are finding that donors' arms have suddenly gotten too short to reach their pockets. (And by the way, how many of you tossed in a sawbuck for the Kashmir earthquake? I thought so.)

In some circles, of course, the divine vengeance and/or end times theories are popular, but we'll let those circles turn on their own. Over here, I'll say that while many people have the impression that major earthquakes have become more frequent of late, statistically that does not seem to be the case. There probably is something to the theory that global warming is making very powerful hurricanes more likely, and we are indeed in a natural cycle of more frequent tropical cyclones.

But the basic reasons why, over the long term, we are hearing of more and worse natural disasters are: 1) The human population is greater than ever, and more of the earth's surface is densely populated by humans, including coastal areas vulnerable to storms and tsunamis; 2) Modern communications, rapid travel, economic globalization and international affairs have made us far more aware of events in formerly remote places. Even 20 years ago, I doubt that an earthquake in Kashmir would have been very big news in the U.S.

There are rational responses to natural dangers, obviously, but as with every problem there are issues of justice and social class. Poor people are more vulnerable for several reasons. They live in flimsier houses (in the case of Kashmir, in unframed masonry buildings with no chance of withstanding even a moderate earthquake); are more likely to live on low or otherwise vulnerable ground (viz. the 9th Ward of New Orleans); and have fewer resources to escape or recover (ibid).

In an enlightened world, we would anticipate these problems. At the very least, we can account for them in how we recover and rebuild. If the poor people of Kashmir have no option but to once again pile up bricks and concrete slabs, the next earthquake will have the same result. Here in the wealthy U.S., the west coast cities threatened by earthquakes have steadily been improving their buildings and bridges. Some say they haven't done as much as they should, but they've done enough that a major earthquake striking San Francisco Bay or Los Angeles County, while it will be a significant disaster, will probably cause deaths in the scores or possibly hundreds, not tens of thousands as in Kashmir.

So these events are natural, but their disastrous nature is to some extent amenable to human control. Never forget that.

Monday, October 17, 2005

College-educated east coast liberals are often baffled, bothered and bewildered by most of what passes for political discourse in this country. How can it be that the events of Sept. 11, 2001 were supposed to be a reason to vote for George W. Bush in 2004? Why does the prospect of lesbians and gay men getting married in Massachusetts send the voters of the Midwest into a raging panic over the pending destruction of their own families? (Huh?) Why are people who stock shelves in WalMart passionately committed to cutting the capital gains tax and eliminating the estate tax?

But some the weirdest events since the alien invasion concern that flagship institution of east cost liberal elitism, you know what I’m talking about, it’s the All the News that Fits, $60 dollar entrée restaurant reviewing Newspaper of Record, the New York Times.

In the 1990s, the Times developed an obsessive, pathological hatred of the Clintons, who they pursued like furies with an almost weekly outpouring of 2- and 3-page stories relating incomprehensible details of fictitious scandals, and near-daily editorials calling upon them to be tarred, feathered, pilloried, imprisoned, drawn and quartered, hung, stretched on the rack, burned at the stake, keelhauled, flogged and made to sit in the corner – all over a campaign of scurrilous rumor and slander financed by a wealthy far right fanatic, and even though that same editorial page was in perfect lockstep with Clinton administration policies.

In the 2000 presidential campaign, their political coverage devolved to the level of giggling schoolgirls, obsessed with the color of Al Gore’s suits and endlessly recycled falsehoods about trivial things he had supposedly said in informal settings; while showing not the slightest curiosity about George W. Bush’s past or the blatant lies and contradictions in his campaign promises. Once the Republican aparatchiks on the Supreme Court appointed Bush president, the newspaper’s White House bureau had the hounds of hell put down and started concentrating on the new president’s wondrous affability and his favorite flavors of ice cream. No scandals in the Bush administration, no sir!

Then, after a bunch of buildings in their own city got knocked down while their best buddy was listening to a story about a goat, they started channeling the Office of Special Plans, a propaganda organ set up in the Pentagon to concoct phony intelligence about Saddam Hussein building nuclear weapons to give to Osama bin Laden. The medium, of course, was "reporter" Judith Miller, who had her stories dictated by Douglas Feith and the Pentagon's candidate for future president of Iraq, convicted embezzler Ahmad Chalabi. After they would plant a story in the Times, the Vice President, Secretary of Defense, and various minions would go on TV talking head fests to say, "See, even the pointy head liberal New York Times says it so it must be true."

Now we have the mind-boggling affaire Plame. Patriotic Americans tried to call the war plotters on their lies were excoriated by the Vice President and DoD officials as appeasers, dupes, haters of America, collaborators with terrorists, and the corporate media was happy to pile on. Then Ambassador Wilson was sent by the CIA to check out allegations (that turned out to be based on mysteriously forged documents), which had been used by Mr. Bush as a central justification for war in his State of the Union speech. Wilson publicly declared the allegations to be false, so the conspirators started spreading the lie among reporters that he had been nominated for the job by his wife, who by the way is a CIA agent responsible for investigating chemical, biological and nuclear weapons in the Middle East, thereby destroying her operation and possibly endangering the lives of her collaborators and informants.

And we have sacrificed 2,000 of our young people's lives, forever broken the bodies of 20,000 more, killed more than 100,000 Iraqis, spent more than 200 billion dollars with no end in sight, brought shame and dishonor upon the country and won the contempt and anger of the whole world precisely why? They told us that the reason was to stop the development of chemical, biological and nuclear weapons in the Middle East.

One of the people they discussed this classified information with was Judith Miller, who was not writing a story on the subject. Rather than testify as to who at the highest levels of government had committed an act of treason in order to protect previous treasonous lies, Ms. Miller declares herself a martyr to journalistic integrity and principle and spends 80 days in jail. The Times writes weekly editorials extolling her noble cause, gushing tears of pain and anger over an out-of-control prosecutor who would expect reporters and public officials to obey the law, and claiming without a trace of shame that the public interest depends on journalists concealing the truth from the public when their powerful friends commit treason. In furtherance of this ethical stance, the Times does not cover the story in its news pages.

The final denoument is if anything even more bizarre, but I won't waste your time pounding on what others have already beaten to a pulp. (I recommend Wolcott as a good starting point if you have yet to explore the blogosphere on this.)

Discussion of my earlier posting on the participation of physicians and other medical professionals in the torture of prisoners in Iraq, Afghanistan and Guantanamo Bay centered on whether the perpetrators can be held accountable by licensing boards.

Steve Hellig of the Cambridge Quarterly of Healthcare Ethics and colleagues Phillip Lee and Marcus Conant, in a letter to NEJM, call for precisely that:

Those who have served in the U.S. military know that there is a documented chain of command for every action. Health care personnel serving in the military all work under the authority of licensed military physicians, who are responsible for actions performed under their authority. We therefore call on the AMA and the American Psychological Association to request that relevant authorities act, at a minimum, as follows. First, the military must provide full disclosure of all medical personnel involved, directly or by chain of command, in the treatment of detainees in Iraq, Afghanistan, and Cuba - and elsewhere if relevant - since September 11, 2001. Second, the records and conduct of these personnel should be reviewed by the medical licensing boards, other responsible licensing authorities in each state where the military physicians are licensed, or both. Independent expertise in bioethical standards should be sought in conducting these reviews. Third, appropriate disciplinary action should be taken on the basis of the results of the reviews, and these actions should be made publicly available.

Of course, it is highly unlikely that the military will respond to such a request. The physician and psychologist perpetrators, if publicly identified, would no doubt offer in their own defense the names of the superior officers who ordered them to commit crimes. And as we know, the Department of Defense is not going to allow accountability for these atrocities to climb the chain of command. After all, where would it stop?

Sunday, October 16, 2005

In ancient times, people looked up at the sky and it appeared that the sun, moon and stars were revolving about them. The ancient Greeks studied the heavens more closely and noticed that, along with the sun and moon which wandered among the apparently fixed stars, there were a few stars that also wandered. Based on the geocentric assumption, Ptolemy devised a mechanical model of the universe in which the heavenly bodies were embedded in crystal spheres, rotating about the center of the earth. (By the way, the Greeks were well aware that the earth was spherical, and even produced a very accurate estimate of its diameter.) Obviously, something must keep the heavenly bodies from falling to the earth as everything does, but that something must be invisible, so crystalline spheres seemed to do the trick.

Over the ensuing centuries, closer observations of the planets challenged Ptolemy's model. They would acclerate and decelerate, even briefly reverse direction. The solution was to make the centers of their spheres themselves rotate about other centers, rather than being fixed. Even these solutions failed upon more exact measurements, and so the epicycles needed epi-epi-cycles of their own.

In 1514 the Polish mathematician Nicolas Copernicus gave a handwritten book to a few of his friends. In it he declared seven of what he called "axioms," though they are in fact deductions:

There is no one centre in the universe.#The Earth's centre is not the centre of the universe.#The centre of the universe is near the sun.#The distance from the Earth to the sun is imperceptible compared with the distance to the stars.#The rotation of the Earth accounts for the apparent daily rotation of the stars.#The apparent annual cycle of movements of the sun is caused by the Earth revolving round it.#The apparent retrograde motion of the planets is caused by the motion of the Earth from which one observes.

In 1543, shortly before his death, he published the full elucidation of his theory under the title "On the Revolutions of the Heavenly Bodies." He had deduced a much simpler explanation of astronomical observations. Galileo then used a new invention, the telescope, to make observations which conclusively proved the theories of Copernicus. For example, he observed the phases of Venus, which demonstrated that it revolved around the sun. He also discovered moons of Jupiter, which would have smashed its crystalline sphere, although neither he nor Copernicus had any way of explaining what held the heavenly bodies aloft.

As we know, the Pope and his lieutenants refused to look through the telescope. They threatened to torture Galileo to death, in the name of Christ, if he continued to defend the Copernican system, and he relented. But the truth could not be denied. Kepler improved on Copernicus by determining that orbits were not circles, but ellipses; Newton developed a mathematical theory of gravitation which, among other achievements, finally demolished the conception of any "center" of the universe (something which Copernicus had somehow intuited, but not pursued). By the late 19th Century, improved telescopes and observational and analytic methods had made it possible to prove that the stars were trillions of kilometers from the earth, and were objects similar to the sun. By the 1920s, astronomers had determined that the stars occupied a volume a few hundred thousand light years across, the Milky Way galaxy, which they believed constituted the entire cosmos.

Then Edwin Hubble discovered that most of the objects known as nebulae are not, in fact, clouds of gas, but other galaxies beyond our own, millions of light years away. Then he discovered that distant galaxies are moving away from our own at substantial fractions of the speed of light -- that the universe is expanding. From this astonishing revelation, scientists were able to begin to deduce the history of the universe, and to speculate on its ultimate fate. Our universe -- everything we can observe, that is, although quite possibly not everything that is or has been or may be -- is about 13 1/2 billion years old. The earth came along much later, about 4 1/2 billion years ago. The universe is so vast that there is no referrent to human experience in the distance to even the closest star, while that distance is but a hundred thousandth of the width of the galaxy. The nearest galaxy (other than two satellites of the Milky Way), Andromeda, is almost 3 million light years away.

Here is a portion of an image called the Hubble Deep Field, looking out in space and back in time nearly 12 billion years. This is a tiny piece of the sky, smaller than the end of a pencil held at arms length:

Each of the galaxies in the image -- and the tiny red dots are very distant galaxies -- contains on the order of 200 billion stars (as does our own).

These discoveries have smashed completely, and forever, the biblical cosmos. If there is a sentient creator of the universe, the purpose of the creation cannot possibly have had anything to do with us. The universe is utterly indifferent to our existence, which is of not the slightest consequence. A million galaxies like our own could vanish in an instant, and the universe would go on, not recognizably changed. This is the cosmos that we have discovered with our senses, and our reason, and our wondrous tools. But it is very difficult for most people to accept, and most people do not accept it. Two hundred thousand years of cultural development, of attitudes about the world, of explanation, of belief; the bedrock of the social order in religious authority, the answer to the terror of death and the futility of bereavement, the anchor of purpose; all swept away in a few hundred years, in a devastating avalanche of nearly incomprehensible truth.

It is no wonder that we are experiencing a turning away from reason, and truth, a flight into comforting darkness. Perhaps we have elevated such a limited, willfully ignorant man to our highest office precisely because his limitations are comforting. But the dark ages must be over now. If we are going to survive the challenges ahead of us, we must step out into the light, no matter how painful, and never turn back.

Saturday, October 15, 2005

Some of you may remember that in Bill Cosby's version of the story, God tells Noah "I'm gonna make it rain for a thousand days and a thousand nights and drown 'em right out." Noah replies, "Why don't you just make it rain for forty days and forty nights and wait for the sewers to back up?"

Well, here in New England, we're proving that it doesn't even take forty days. Nevertheless, I intrepidly headed out in my amphibious vehicle yesterday to the Critical MASS conference in Shrewsbury, where a determined crowd of fellow water rats met to carry on the movement to eliminate health disparities. That's right, a lot of us think that this ought to be, can be, will be, the next big crusade to make this country better.

Let's not forget, in spite of the appalling state of politics in this country right now, and the descent of journalism into the lowest depths of whoredom, in my not yet terribly long life we have traveled forward a long way. We had the Civil Rights Movement, and while racism certainly hasn't gone away and the right to vote is under assault, racial discrimination is illegal and far fewer people are disenfranchised today than in 1960. We had the Women's Movement and while we are still facing a backlash anybody who doesn't think it made a huge difference hasn't been paying any attention. We passed Medicare and Medicaid and again, they're under pressure, but they aren't going away. Even the Gay Rights Movement has changed the terms of discourse, and made a major difference in the culture in some parts of the country. Our leaders still lie to us, but we're less tolerant when they do. It took the people too long to catch on to the ways they had been deceived and manipulated into war in Iraq, but it happened much faster than it did in the case of Vietnam.

Now we happen to think that if we can raise consciousness enough, organize effectively, frame the issues in the right way, the American people won't tolerate the huge differences in health, life expetancy, and the adequacy and quality of health care that people get because of their race, ethnicity, culture, or the kind of work they do and where they happen to live. It just isn't right, and I happen to think that the American people are good people and most of us won't put up with it.

We have a coalition here in Massachusetts, and even political leadership in Rep. Peter Kotoujian, Sen. Diane Wilkerson, and many of their colleagues, who are ready to take on this fight. There isn't any reason why we can't find people to join with in our neighboring states, and the rest of the U.S., to make this an effective national movement. How about where you live?

Friday, October 14, 2005

David Bacon in The Nation, Oct. 24 tells us about indigenous people from Central America and southern Mexico who travel north through Mexico, working on plantations, and on to California. (The full article is available to subscribers only, but if you haven't subscribed yet, now's the time.) Their community endures although their place is lost. One of the places he mentions, on the journey north, is San Quintin in Baja California.

I visited San Quintin some years ago. Heading south from Ensenada, the trans-penninsular highway is a black thread through sand to the horizon. Even the sparse cacti are small and very mean, with needle-like thorns longer than their barrels are thick. Every forty miles or so a sign with a place name points west toward the ocean, marking a barely discernible track of tire marks. Every 100 miles, a Pemex station and a tiny huddle of cinderblock houses, with a patch of wilting cabbages and a starving cow. On this alien planet, battered flatbed trucks with high wooden panels roar past in the single northbound lane, heaped with tomatoes, grapes and bell peppers.

Then you go over a mountain pass and spread out below is a glistening emerald valley. Come a couple of miles further on down the slope and you'll see it resolve into endless rows of tomatoes and grapes, here and there a small cloud of dust raised by gangs of workers. An actual paved side road, the first in a hundred miles, leads toward the ocean. The road is washed out in places, but still passable in our old Buick. Lined by majestic, but dying eucalyptus trees, it leads to a resort called Cielito Lindo -- a cluster of cabins in the style of a 1950s New Jersey motel, a coffee shop, a restaurant and bar, and a campground with RV hookups for surfers. Just across a narrow inlet is a luxury hotel with a helipad, called El Presidente, owned by the Mexican government as a resort for wealthy Mexicans. The sand is just like granulated sugar with flecks of cinnamon, the sun and surf never end. The ocean, frigid from the Alaksa current, keeps the days just warm and the evenings cool in this tropical desert, while three miles inland the afternoon temperatures are 120 degrees.

A jug of water sits by the sink in every cabana. The tap water has been ruined by salt water intrusion, from years of pumping out the aquifer to water the plantation up in the desert valley so the tomatoes and grapes could be sent on to California canneries and wineries. About a dozen American retirees lived in Cielito Lindo, in dirt cheap luxury. They hadn't bothered to learn a word of Spanish. They would order the servants about imperiously in English, and just yell at them when they didn't understand. Back up by the highway is the village, a huddle of 400 square foot cinderblock boxes. There's a grassy meadow with a sign reading "No Cazar," no hunting, and a man sitting on a horse with a gun across his lap to make sure it doesn't happen. The locals have some sagging corn stalks and bug-eaten cabbages, but without any rights to irrigation water, they can barely pull a week of lunches out of the ground in a year. Down the road a bit, and closer to the shore, a weathered sign reads, in Spanish: This is the ejido of the Happy Valley. The government gave this land to the peasants, for ever. Ejidos were supposed to be communal estates awarded to peasants in a land reform program. This land is clay, salted from the occasional hurricanes that wash the ocean over it, deepy gullied, barren and useless.

With my wretched Spanish I got the whole story from the locals. The plantation, and the resort, were owned by a man who now lived in Palm Springs California. In an amicable divorce, he had given his American wife ownership of the resort. Their daughters came down during the summer to spend time with their mother, learn Spanish, and get to know the empire they would inherit. There were almost no working age men in the village. They were all north in California, where the money was better. Those lucky enough to have jobs in the resort or the hotel had better housing on the premises. A few survived by fishing and crabbing in the shallow, muddy bay, and there was the proprietor of the general store and the manager of the Pemex station.

Labor on the plantation was done by women, a few old men, and indigenas from the south, who lived in barracks. The indigenas would learn some Spanish and the ways of plantation labor, before they too headed north for the agricultural minimum wage in the U.S., to be replaced by a new cohort of Mayans. Some old Indian women, instead of working in the fields, would sit on the beach with piles of clams to sell to the gringo tourists.

On the side of every building there were spray-painted slogans of the Socialist Workers Party. But when they counted the votes, the PRI always won.

Thursday, October 13, 2005

I never do these appeals, but with all the natural disasters hitting this past year, it might be high time.

The news out of the regions struck by the massive earthquake this past weekend is heartbreaking. Around 40,000 dead, and that total may climb significantly, 2.5-5 million homeless...the worst part is that the worst-hit villages are only now starting to get aid. People have been starving (it's Ramadan, many of these people were fasting when this hit) and freezing while they brave the elements outside (the weather can be brutal this time of year - they already were out in a hail storm, heavy rain...and now snow might be moving in the Kashmir area). Two big tremors hit, 5.3 and 6.2 on the richter scale. The UN and other relief agencies on the ground are asking governments and people for as much help as possible. People don't have blankets, food, basic medicine, any shelter, etc. A total catastrophe, and it's probably getting worse by the minute.

It's all a lot to process. I have a lot of family in northern Pakistan where this hit. The 20-story building that collapsed in Islamabad is pretty close to where some of them live. Everyone over there is completely petrified.

Lots of people have been asking how they can help in the relief effort. I can think of 2 ways:

1) Call up your Senators and Representatives...encourage them to push for more aid. Last I checked, the US pledged $50 million, less than what we spend in Iraq each day. While $50m isn't nothing, it's less than small countries like Qatar and Kuwait have given. (And no, we haven't done nearly enough in response to Katrina, either - unbelievable, we'll spend billions to bomb and occupy, but have to be shamed to spend anything to save lives). Pakistan is an incredibly poor country, they just don't have resources to handle this, and need all the help they can get.

My colleagues the Reveres and I are often asked why we discuss religion so much on our public health blogs. For me, it's largely pragmatic. I tried to move my more basic, philosophical concerns off of this site to the Dialogue blog. (Which is in suspended animation right now, but I'm still hoping to find some participants who are willing to represent the side of religion.) However, there are essential problems in public health in which religion is deeply entangled.

These include the allocation of potentially life saving and health producing resources, end of life treatment and extension of life, abortion, embryonic stem cells, contraception, HIV and STD prevention, drug abuse treatment and prevention and harm reduction . . . All of this is obvious because these are issues prominent in current political controversies. There happens to be a faction of Christians in this country right now, who have effective control of the Executive Branch and dispositive power in the Congress, whose beliefs about all of these issues stand in the way of what scientific knowledge and rational analysis show to be the policies that would bring about the greatest enhancements in population health and longevity.

Now, I admit there is an underlying conceptual principle of the good on which they may differ with me. Their preferred policies would result in more babies being born in the first place, and if someone believes that constitutes The Good, then I'm a bad guy. But those babies would have worse lives, unhappier lives, and shorter lives, than would the fewer babies born in my world. They would have less freedom, less personal autonomy, suffer more sickness, and be materially poorer. Perhaps some people think that is a price worth paying, but I am making my own position clear: it is not. It is also entirely unclear to me what these purportedly Christian views have to do with Jesus, but perhaps that is beside the point.

I bring this up now because Mr. Bush has declared that the reason he believes Harriet Miers should be a Justice of the Supreme Court is that she is an evangelical Christian, whose faith condemns abortion and homosexuality. Mr. Bush's friends James Dobson and Pat Robertson enthusiastically endorse that view and threaten Senators who vote against her with political extinction.

We face a profound historical crisis in this country. Secularists -- and that includes athesists, agnostics, and people of all faiths who believe that religion is a personal matter and that government must represent all people without regard to their religious persuasion -- must stand up proudly, confidently, and publicly and declare that the United States is a pluralist democracy, committed to the advancement of religious and intellectual liberty, and that George W. Bush, James Dobson, and the entire movement that they represent is antithetical to our traditions, our values, and our hopes for the future. And then we need to throw them onto the dustheap of history.

Wednesday, October 12, 2005

Many a heart is aflutter over speculation that Special Prosecutor Patrick Fitzgerald may be journeying into the heart of darkness, past the mere trading outpost of l'affaire Plame to the very conspiracy that gave us the Iraq war. As Nostradamus, Jean Dixon and Thomas Friedman all prove, one need not lose credibility for making false predictions, so I'll go ahead and say that I can't see the criminal investigation going significantly beyond unauthorized disclosure of classified information and some ancillary perjury and conspiracy to obstruct justice. That certainly shouldn't disappoint anyone, but the speculation about busting the gang for conspiracy to commit war points to a larger truth.

The Iraq war is, of course, a crime, and its architects and perpetrators -- who are at the summit of power in the world -- are criminal conspirators. We can label the crimes mass murder, the theft of billions of dollars, treason, and they've even thrown in sexual assault and rape to make it a complete package. But those are only crimes in a certain vernacular sense. No doubt the right prosecutor, judge and jury could find the defendants guilty of various provisions of the criminal law along the way, but that will never happen. For a president to order U.S. troops to kill innocent foreigners, no matter how false the pretenses, will never be construed as a crime, so long as the U.S. political structure remains intact.

Richard Nixon was impeached and removed from office for, in essence, conspiracy after the fact in a burglary. Some members of Congress moved to include an indictment for the secret bombing of Cambodia, but they failed. Lyndon Johnson used false pretenses to get authorization for massive escalation of the Vietnam war, but it never occurred to anyone to prosecute him. Ronald Reagan and his Vice President George Bush the First sold sophisticated weapons to Iran's ayatollahs and donated the proceeds to Nicaraguan terrorists. The price they paid was some inconsequential congressional hearings which converted bag man Oliver North into a hero. Bush the First and Donald Rumsfeld conspired with Saddam Hussein to bring about the slaughter of millions in a pointless war with Iran, but that was just the conduct of foreign policy. I could go on for pages but you get the idea.

Some relatively trivial conduct of Rove and Libby may get them into some fairly minor trouble, though one would hope at substantial political cost. But that is the worst the law will do in this matter.

It is indeed necessary that people with very heavy burdens of command have some immunity from judgment in hindsight. Any military action, after all, would be criminal in a different context. It is the job of soldiers to kill, and it is the job of presidents, at times, to order them to do so. Pacifists may wish it were otherwise, but so it is. Sometimes those orders will be based on erroneous beliefs, or bad judgment. We cannot ordinarily define such mistakes as crimes, no matter how awful the consequences. Power to make consequential decisions is a burden that magnifies human frailty, but still must be wielded by humans. Turning to my own field of expertise, consider physicians. Every single one of them has made mistakes that have hurt or even killed people, but they are not criminals, or bad people, just mortals.

The United States Senate will soon vote on S. 1716, the Emergency Health Care Relief Act of 2005. The bill is sponsored by Senate Finance Committee Chairman Charles Grassley (R-IA) and ranking Democrat Max Baucus (D-MT). This bill would ensure that Katrina survivors have access to health services by providing immediate Medicaid coverage to victims of Hurricane Katrina -- expanding Medicaid eligibility for this population for 5 months, renewable for another 5 months if necessary. The bill would also create an emergency fund for health expenditures that would allow Katrina survivors to maintain their employer-sponsored health insurance coverage and receive financial support for uncompensated care. These two provisions guarantee that Katrina survivors have access to a wide range of services, ranging from primary and preventive healthcare to needed mental health services. Among other things, the bill would provide federal support to the Medicaid programs of Louisiana, Mississippi and Alabama, by fully paying for all program expenditures. States that are hosting Katrina survivors would receive a 100% federal match for services provided to evacuees.

TAKE ACTION NOW. Send an electronic letter to your senators urging them to support S. 1716.

The administration, of course, has been quietly trying to undermine this bill.

Tuesday, October 11, 2005

Picking up the NYWT today, I see a piece by Gardner Harris and Seth Mydans, lead:

As worries increase about the possibility of a flue pandemic, public health officials are hoping that this year's flu season will be the first in years with an abundance of vaccines.

They go on to say that demand for vaccines has been up this year, but that there should be plenty to go around in the U.S. Then they talk about Michael Leavitt's trip to Asia to encourage international cooperation in response to the threat of a pandemic.

What they don't seem to understand -- they certainly never say so and clearly imply otherwise -- is that the flu vaccine which will be available this year will be of absolutely no use against a pandemic of the new H5N1 strain of avian flu. In today's editorial on the subject, Gail Collins and the gang don't appear to get it either. They write: "No country has enough medicines or vaccines to control a widespread outbreak of the avian influenza now circulating . . ."

No. Wrong. No country has any vaccines whatsoever to control a widespread outbreak, or for that matter a small outbreak. No vaccine against this threat exists. There is an experimental vaccine against H5N1 flu, which has not been approved for use, for which no production capability exists, and which may not be effective against any actual human transmissible strain which emerges.

I post this because it is so widely misunderstood, not only at the NYWT but among a large segment of the blogosphere and in my own hometown fishwrapper, and I'm sure in lots of other places as well. Now I'm off to write a letter to the editors, which will not be published.

One of the great things about being a blogger who teaches in higher education is that you get to rip off your students. So thanks to Marlene for getting me a head start on this post. Revere has a post about poultry workers in the U.S. who haven't been informed about the risk of infectious disease from birds. I'm not sure how likely it is that bird flu is actually going to come to the U.S. via poultry, but here are a few facts worth remembering about the people who now bring you breakfast, lunch and dinner in the U.S.

The majority of agricultural workers in the U.S. are immigrants - no surprise. In states with large numbers of immigrants, they also predominate in kitchen work. About half of the immigrant workforce is Latino (people from the Spanish speaking countries of Latin America, predominantly Mexico but increasingly including Central and South America. Puerto Ricans are not considered immigrants, although they are Latino.) Foreign-born Latino workers suffer occupational fatalities at a rate of about 6.1/100,000, compared with 4.6/100,000 for all U.S. workers, according to an analysis by Scott Richardson. Latino men have a 50% higher risk for non-fatal occupational injuries than all workers. And the trend is for increasing rates of occupational injury and death among immigrant workers.

Not only do immigrant workers tend to be in dangerous occupations, they are often unaware that they in the U.S., there are laws establishing workplace safety standards. Undocumented workers, obviously, are generally afraid to assert their rights even if they know about them. Many are paid under the table and their employers do not carry workers' compensation insurance for them. If they are injured, the employer may get them some basic medical treatment, but they will not receive any disability pay or rehabilitation.

The U.S. makes only a symbolic effort to restrict illegal immigration because employers like having a ready supply of exploitable workers willing to work at low pay, in dangerous conditions, who are difficult to organize. By keeping the threat of deportation over the heads of undocumented workers who do surface, while making no real effort to discourage employers from hiring them, the government gives employers exactly what they want. The ethical analysis of immigration of unskilled workers is complicated, and the appropriate policy response is not obvious either. But the fact is, these people are here, getting themselves injured and killed to put chicken on your table.

Monday, October 10, 2005

Sorry for light posting lately (in case anyone has a jones for this site) but I've had computer problems. I had to restore my operating system, which means also struggling to restore all my applications and security settings. I haven't been able to convince my firewall to work with Firefox yet, so I am violating the essential tenets of my religion by making this post with Explorer. Also no e-mail till tomorrow.

Anyway, this little problem got me to thinking. Most of the people of the earth do not have telephones, let alone computers and blogs. Most people in very poor areas now do have access to information from radio broadcasts, and even remote villages often have a battery operated television, a tiny window into a parallel universe of refrigerators, offices, supermarkets, mothers hauling their daughters to ballet lessons in SUVs. Yet we, who have almost instant access to the libraries of the world, are largely unaware of them. We see the odd famine or natural disaster on the nightly news, but in the wealthy countries, it is only a small minority who pays any attention to what life is like in most of the world in ordinary times.

I have hammered away on this theme of the so-called Christian ideology of a "culture of life" in a world in which far more thinking, feeling, suffering people die every week of HIV than there are comatose people on life support in all the world. Every year, six million children starve to death before their fifth birthdays, while there are about 1.2 million abortions in the United States. Like me, these rich, well-fed, well-housed, politically well represented Christians have time, money, and access to channels of communication to press their causes. They claim to speak for those who cannot speak for themselves. It is nonsensical to imagine what a fetus would say if it could speak, since it has no awareness and no experience. But I know what those starving children are saying.